Observational Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Dec 27, 2021; 13(12): 2150-2160
Published online Dec 27, 2021. doi: 10.4254/wjh.v13.i12.2150
Determination of “indeterminate score” measurements in lean nonalcoholic fatty liver disease patients from western Saudi Arabia
Yasir Mohammed Khayyat
Yasir Mohammed Khayyat, Department of Medicine, Umm Al Qura University, Makkah 13578, Saudi Arabia
Yasir Mohammed Khayyat, Department of Medicine, International Medical Centre, Jeddah 21451, Saudi Arabia
Author contributions: Khayyat YM conceived of and designed the study, collected the data, and wrote the article, providing final approval of the manuscript to be published.
Institutional review board statement: The Institutional Review Board of International Medical Centre, Jeddah, Saudi Arabia provided approval for this study (IRB No. 2019-11-215).
Informed consent statement: The requirement for consent was waived considering that there was no more than minimal risk to the subjects related to performance of FibroScan and blood tests measurements. The waiver was ensured to not adversely affect the rights and welfare of the subjects, in which tests performed were already completed, regardless of the research.
Conflict-of-interest statement: The author declares having no conflicts of interest related to this study and its publication.
Data sharing statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Yasir Mohammed Khayyat, FACP, FRCP (C), MBChB, Associate Professor, Department of Medicine, Umm Al Qura University, Al Abdiyah District, Makkah 13578, Saudi Arabia. ymkhayyat@uqu.edu.sa
Received: March 24, 2021
Peer-review started: March 24, 2021
First decision: June 15, 2021
Revised: June 24, 2021
Accepted: October 17, 2021
Article in press: October 17, 2021
Published online: December 27, 2021

Noninvasive measures to estimate liver fibrosis in lieu of biopsy in nonalcoholic liver disease (NAFLD) can broadly differentiate high vs low degrees of condition extent. However, an “indeterminate score” necessitates further clinical investigation and biopsy becomes essential, highlighting the need for identification of other noninvasive factors with accuracy for this midlevel extent and its prognosis. Lean NAFLD cases are of particular interest regarding this issue, as they present as otherwise healthy, and will benefit greatly from the less invasive assessment.


To estimate the agreement of two noninvasive assessment tools in lean NAFLD patients, and assess factors related to indeterminate scores.


Ultrasound-diagnosed NAFLD patients, without sign of other chronic liver disease (n = 1262), were enrolled from a tertiary private medical centre between 2016-2019. After grouping by body mass index (obese, overweight, and lean), each participant underwent FibroScan. NAFLD fibrosis score (NFS) was used for subclassification (lower, higher, and indeterminate). No patient underwent liver biopsy. The kappa statistic was used to assess inter-rater agreement between the three groups on liver fibrosis degree assessed via FibroScan and NFS. Indeterminate score among the three groups was assessed to identify factors that predict its determination.


The NAFLD study cohort was composed of lean (159/1262, 12.6%), overweight (365/1262, 29%) and obese (737/1262, 58.4%) individuals. The lean patients were significantly younger (49.95 ± 15.3 years, P < 0.05), with higher serum high density lipoprotein (52.56 ± 16.27 mg/dL, P < 0.001) and lower prevalences of type 2 diabetes mellitus, hypertension and hyperlipidaemia. All groups showed a predominance of lower fibrosis degree. The lean NAFLD patients showed a significantly lower NFS (P < 0.001). Degree of agreement between FibroScan and NFS was fair between the lean and obese NAFLD categories, and moderate in the overweight category. NFS was predictive of indeterminate score. Age was a factor among all the body mass index (BMI) categories; other associated factors, but with less strength, were serum alanine aminotransferase in the overweight category and BMI in the obese category.


Lean NAFLD patients showed lower degree and prevalence of liver fibrosis by NFS; however, follow-up biopsy is still needed.

Keywords: Nonalcoholic fatty liver disease, Liver fibrosis, Liver biopsy, Obesity, Overweight, Lean

Core Tip: Nonalcoholic fatty liver disease (NAFLD) has emerged as a leading cause of chronic liver disease and its complications. Evaluation of fibrosis in NAFLD is of the utmost importance to early application of targeted intervention. The utilization of liver biopsy has diminished, due to patient unacceptance, sampling error, and availability of noninvasive measures of fibrosis. In this study of NAFLD cases, lean patients showed a relatively healthy metabolic profile, lower fibrosis degree and less frequent “indeterminate score“ than overweight and obese patients, among which increased age and serum alanine aminotransferase level were predictive factors for determination.