The impact of metabolic dysfunction-associated steatotic liver disease on non-invasive fibrosis scores in patients with chronic hepatitis B: a multicenter retrospective study

BACKGROUND: The coexistence of metabolic dysfunction-associated steatotic liver disease (MASLD) and chronic hepatitis B (CHB) may influence liver fibrosis, but the relationship between these conditions remains unclear. MASLD may also affect the performance of non-invasive tests (NITs) in CHB. Recently developed NITs, such as FIB-8 and FIB-9, were designed for MASLD patients but have not been assessed in those with both CHB and MASLD. This study aimed to comparatively assess the diagnostic performance of various NITs for predicting significant fibrosis in CHB patients stratified by MASLD status. METHODS: In this multicenter retrospective study, CHB patients who underwent liver biopsy were analyzed. Significant fibrosis was defined as ISHAK stage ≥ 3, and hepatic steatosis as ≥ 5% fat accumulation on biopsy. The performance of 20 NITs in predicting significant fibrosis was assessed in the overall cohort and in MASLD-positive and MASLD negative groups. RESULTS: A total of 1545 patients were included, of whom 328 (21.2%) were MASLD-positive. More than half of the MASLD-positive patients had a single cardiometabolic risk factor. In the MASLD-negative group, FIB-4 showed the highest area under the receiver operating characteristic curve (AUROC) value (0.660), whereas in the MASLD-positive group, the highest AUROC was observed for FIB-8 (0.728). Furthermore, the FIB-8, Lok, and ATA scores demonstrated significantly higher AUROC values in the MASLD-positive group than in the MASLD-negative group (0.728, 0.726, and 0.716 vs. 0.535, 0.590, and 0.600, respectively; p = 0.008, 0.002, and 0.008). No significant differences were observed in the performance of the remaining NITs according to MASLD status. CONCLUSIONS: The diagnostic performance of NITs for predicting significant fibrosis in CHB patients varies according to MASLD status. FIB-8, Lok, and ATA scores demonstrated significantly higher diagnostic accuracy in MASLD-positive patients, suggesting that metabolic factors may influence the discriminative capacity of fibrosis markers. Nevertheless, all evaluated NITs demonstrated low-to-moderate diagnostic performance across all groups, limiting their standalone clinical utility and highlighting the need for more accurate non-invasive fibrosis models in this population. TRIAL REGISTRATION: Not applicable.