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Ballestri et al. Metab Target Organ Damage 2023;3:13 Metabolism and
DOI: 10.20517/mtod.2023.21
Target Organ Damage

Commentary Open Access

Ultrasonographic fatty liver indicator (US-FLI): a
reliable biomarker for non-invasive NAFLD

stratification

1
Stefano Ballestri , Amedeo Lonardo 2
1
Internal and Rehabilitation Medicine, Department of Internal Medicine, Hospital of Pavullo, Modena 41026, Italy.
2
Metabolic and Neural Sciences, Azienda Ospedaliero Universitaria di Modena - Ospedale di Baggiovara, Modena 41026, Italy.
Correspondence to: Dr. Stefano Ballestri, Internal and Rehabilitation Medicine, Department of Internal Medicine, Hospital of
Pavullo, Azienda USL of Modena, Via Suore di S. Giuseppe Benedetto Cottolengo 5, Pavullo nel Frignano, Modena 41026, Italy. E-
mail: stefanoballestri78@gmail.com
How to cite this article: Ballestri S, Lonardo A. Ultrasonographic fatty liver indicator (US-FLI): a reliable biomarker for non-
invasive NAFLD stratification. Metab Target Organ Damage 2023;3:13. https://dx.doi.org/10.20517/mtod.2023.21
Received: 27 Jun 2023 First Decision: 9 Aug 2023 Revised: 16 Aug 2023 Accepted: 21 Aug 2023 Published: 29 Aug 2023

Academic Editor: Sonia Najjar Copy Editor: Yanbing Bai Production Editor: Yanbing Bai

Abstract
Here, we comment on a recent article supporting the use of the ultrasonographic fatty liver indicator (US-FLI) as a
point-of-care biomarker to be used in the community to rule out nonalcoholic steatohepatitis (NASH). To this end,
we discuss definitions and characteristics of US-FLI, and we critically summarize the principal studies published
from 2012 to 2023. We conclude that US-FLI exhibits high reproducibility. It finds utility across both the pediatric
population and the point-of-care settings. Furthermore, it demonstrates a robust correlation with metabolic
derangements, and also serves as a predictive tool for varying grades of hepatic steatosis and important liver
histology endpoints. Notably, it excels in its capacity to differentiate between bland steatosis and true NASH.
However, US-FLI reportedly exhibits limited accuracy among patient populations with obesity. Finally, we propose
a detailed agenda to advance research on US-FLI.
Keywords: Liver biopsy, NAFLD, NASH, ultrasonography

Defined as liver steatosis occurring in the absence of competing etiologies of steatogenic chronic liver
disease (CLD), nonalcoholic fatty liver disease (NAFLD) embraces bland steatosis through nonalcoholic

© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0
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