Prevalence of Low FIB‐4 in MASLD‐Related Hepatocellular Carcinoma: A Multicentre Study

ABSTRACT Background Major society guidelines recommend the fibrosis‐4 index (FIB‐4) as the initial step to risk stratifying people with metabolic dysfunction‐associated steatotic liver disease (MASLD). We aimed to evaluate the proportion of people with MASLD‐related hepatocellular carcinoma (HCC) and a low FIB‐4. Methods This cohort study included 613 consecutive adults (33% female) diagnosed with MASLD‐related HCC from January 2008 to August 2023 at seven international centres in Australia, India, Japan, South Korea, Singapore and the United States. The primary objective was to determine the proportion of participants with a low FIB‐4, defined as FIB‐4 < 1.3, or < 2 if age > 65 years, in people without cirrhosis. Results The mean (±SD) age and body mass index were 71 (±11) years and 27 (±7) kg/m 2 , respectively. Overall, 235 participants (38%) did not have known cirrhosis. The median FIB‐4 was 3.90 (IQR 2.42–6.42). A total of 78 participants (13%) had a low FIB‐4. Among participants without known cirrhosis ( n = 235), 62 participants (26%) had a low FIB‐4. Participants with a low FIB‐4 had larger median total tumour diameter ( p < 0.001) and lower median serum alpha‐fetoprotein ( p = 0.005), compared to participants without a low FIB‐4. Cirrhosis was associated with lower odds of low FIB‐4, but not other factors such as male sex, type 2 diabetes, or obesity. Conclusion More than a quarter of those with MASLD‐related HCC without cirrhosis have a low FIB‐4. The proposed clinical care pathways may not identify these people for further evaluation.