{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,6]],"date-time":"2026-10-06T05:22:47Z","timestamp":1791264167642,"version":"4.1.0"},"reference-count":39,"publisher":"Public Library of Science (PLoS)","issue":"2","license":[{"start":{"date-parts":[[2026,2,6]],"date-time":"2026-02-06T00:00:00Z","timestamp":1770336000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100011614","name":"University of Kelaniya","doi-asserted-by":"publisher","award":["RC\/2024\/G03"],"award-info":[{"award-number":["RC\/2024\/G03"]}],"id":[{"id":"10.13039\/501100011614","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Patients with significant liver fibrosis (SF) are likely to progress to advanced chronic liver disease (ACLD). Therefore, liver-directed therapy is indicated. The European Association for the Study of the Liver-2024 (EASL) recommends annual screening of patients with diabetes for SF\/ACLD using the FIB-4 score, followed by vibration-controlled transient elastography (VCTE) in patients with FIB-4\u2009\u2265\u20091.3 in \u226465-year-olds and \u22652.0 in &gt; 65-year-olds. Because VCTE is not freely available in resource-limited settings, we revised the EASL algorithm to prioritise referrals for VCTE in such settings and validated it in an external cohort.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted a cross-sectional study of adults with type 2 diabetes (T2DM) and ultrasonographic evidence of steatotic liver disease (SDL) attending three outpatient medical clinics in the Gampaha District, Sri Lanka. FIB-4 scores were calculated, and those with scores \u22651.3 underwent VCTE. SF was defined as liver stiffness measure (LSM) \u2265 8.0 kPa. Factors significantly associated with SF\/ACLD were identified using multiple logistic regression (LR). We then developed a new criterion for VCTE referral and compared the number of referrals for VCTE when using the new criterion-based algorithm with the EASL algorithm. We validated the new criterion-based algorithm in an external cohort of 372 patients with MASLD.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>We studied 363 patients, and 128 had an FIB-4 score of\u22651.3. Of them,121 underwent VCTE, and 76 had an LSM\u2009\u2265\u20098.0 kPa. On multivariable LR, VCTE-diagnosed SF\/ACLD was independently associated with diabetes of \u2265 5 years duration (OR 3.8, p\u2009=\u20090.035), micro\/macrovascular complications (OR 19.4, p\u2009=\u20090.016), and BMI of \u2265 25\u2009kg\/m2(OR 6.2, p\u2009=\u20090.003). We revised the VCTE referral criterion as \u201cpatients having EASL FIB-4 criterion plus one or more of the three other factors: diabetes of \u2265 5 years duration, presence of micro\/macrovascular complications or BMI\u226525\u2009kg\/m2,\u201d. The number of VCTE referrals indicated using the EASL algorithm was 96, compared to 83 with the new criterion, resulting in a 13.5% reduction. In the external validation cohort, the new algorithm reduced the number requiring VCTE referral by 15.5%.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Adopting the new criterion for VCTE referral in patients with MASLD appears more cost-effective for detecting SF\/ACLD in low-resource settings in South Asia.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0341364","type":"journal-article","created":{"date-parts":[[2026,2,6]],"date-time":"2026-02-06T18:32:29Z","timestamp":1770402749000},"page":"e0341364","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":2,"title":["Adoption and validation of the European Association for the Study of the Liver algorithm for the noninvasive diagnosis of advanced fibrosis in metabolic dysfunction-associated steatotic liver disease in low-resource South Asian settings"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3328-1553","authenticated-orcid":true,"given":"Chamila","family":"Mettananda","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chamila","family":"Ranawaka","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thimira","family":"Egodage","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Channaka","family":"Dantanarayana","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rumal","family":"Fernando","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lakmali","family":"Ranaweera","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dulani","family":"Kottahachchi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shirom","family":"Siriwardhana","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4065-2639","authenticated-orcid":true,"given":"Arunasalam","family":"Pathmeswaran","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anuradha","family":"Dassanayake","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Janaka","family":"de Silva","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,2,6]]},"reference":[{"issue":"4","key":"pone.0341364.ref001","doi-asserted-by":"crossref","first-page":"1335","DOI":"10.1097\/HEP.0000000000000004","article-title":"The global epidemiology of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH): a systematic review","volume":"77","author":"ZM Younossi","year":"2023","journal-title":"Hepatology"},{"issue":"6","key":"pone.0341364.ref002","doi-asserted-by":"crossref","first-page":"1356","DOI":"10.1002\/hep.510300604","article-title":"Independent predictors of liver fibrosis in patients with nonalcoholic steatohepatitis","volume":"30","author":"P Angulo","year":"1999","journal-title":"Hepatology"},{"issue":"4","key":"pone.0341364.ref003","doi-asserted-by":"crossref","first-page":"793","DOI":"10.1016\/j.jhep.2019.06.021","article-title":"The global epidemiology of NAFLD and NASH in patients with type 2 diabetes: A systematic review and meta-analysis","volume":"71","author":"ZM Younossi","year":"2019","journal-title":"J Hepatol"},{"issue":"12","key":"pone.0341364.ref004","doi-asserted-by":"crossref","first-page":"2364","DOI":"10.1136\/gutjnl-2023-330269","article-title":"Clinical care pathway to detect advanced liver disease in patients with type 2 diabetes through automated fibrosis score calculation and electronic reminder messages: a randomised controlled trial","volume":"72","author":"X Zhang","year":"2023","journal-title":"Gut"},{"issue":"21","key":"pone.0341364.ref005","doi-asserted-by":"crossref","first-page":"2063","DOI":"10.1056\/NEJMra1503519","article-title":"Cause, pathogenesis, and treatment of nonalcoholic steatohepatitis","volume":"377","author":"AM Diehl","year":"2017","journal-title":"N Engl J Med"},{"issue":"2","key":"pone.0341364.ref006","doi-asserted-by":"crossref","DOI":"10.1053\/j.gastro.2018.04.034","article-title":"Fibrosis Severity as a Determinant of Cause-Specific Mortality in Patients With Advanced Nonalcoholic Fatty Liver Disease: A Multi-National Cohort Study","volume":"155","author":"E Vilar-Gomez","year":"2018","journal-title":"Gastroenterology"},{"issue":"17","key":"pone.0341364.ref007","doi-asserted-by":"crossref","first-page":"1559","DOI":"10.1056\/NEJMoa2029349","article-title":"Prospective Study of Outcomes in Adults with Nonalcoholic Fatty Liver Disease","volume":"385","author":"AJ Sanyal","year":"2021","journal-title":"N Engl J Med"},{"issue":"9","key":"pone.0341364.ref008","doi-asserted-by":"crossref","first-page":"2467","DOI":"10.1111\/j.1572-0241.1999.01377.x","article-title":"Nonalcoholic steatohepatitis: a proposal for grading and staging the histological lesions","volume":"94","author":"EM Brunt","year":"1999","journal-title":"Am J Gastroenterol"},{"issue":"21","key":"pone.0341364.ref009","doi-asserted-by":"crossref","first-page":"2063","DOI":"10.1056\/NEJMra1503519","article-title":"Cause, pathogenesis, and treatment of nonalcoholic steatohepatitis","volume":"377","author":"AM Diehl","year":"2017","journal-title":"New England Journal of Medicine"},{"issue":"18","key":"pone.0341364.ref010","doi-asserted-by":"crossref","first-page":"1589","DOI":"10.1001\/jama.2023.5997","article-title":"Diagnosis and Management of Cirrhosis and Its Complications: A Review","volume":"329","author":"EB Tapper","year":"2023","journal-title":"JAMA"},{"issue":"5","key":"pone.0341364.ref011","doi-asserted-by":"crossref","first-page":"528","DOI":"10.1016\/j.eprac.2022.03.010","article-title":"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: Co-Sponsored by the American Association for the Study of Liver Diseases (AASLD)","volume":"28","author":"K Cusi","year":"2022","journal-title":"Endocr Pract"},{"issue":"5","key":"pone.0341364.ref012","doi-asserted-by":"crossref","first-page":"1797","DOI":"10.1097\/HEP.0000000000000323","article-title":"AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease","volume":"77","author":"ME Rinella","year":"2023","journal-title":"Hepatology"},{"issue":"11","key":"pone.0341364.ref013","doi-asserted-by":"crossref","first-page":"2375","DOI":"10.1007\/s00125-024-06196-3","article-title":"EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD): Executive Summary","volume":"67","author":"European Association for the Study of the Liver, European Association for the Study of Diabetes, European Association for the Study of Obesity","year":"2024","journal-title":"Diabetologia"},{"issue":"4","key":"pone.0341364.ref014","doi-asserted-by":"crossref","first-page":"196","DOI":"10.1038\/nrgastro.2016.3","article-title":"Management of NAFLD: a stage-based approach","volume":"13","author":"ME Rinella","year":"2016","journal-title":"Nat Rev Gastroenterol Hepatol"},{"issue":"1","key":"pone.0341364.ref015","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1186\/s12902-022-00980-1","article-title":"Non-alcoholic fatty liver disease (NAFLD): a review of pathophysiology, clinical management and effects of weight loss","volume":"22","author":"S Pouwels","year":"2022","journal-title":"BMC Endocr Disord"},{"issue":"9","key":"pone.0341364.ref016","doi-asserted-by":"crossref","first-page":"1700","DOI":"10.1016\/j.mayocp.2022.04.005","article-title":"Nonalcoholic Fatty Liver Disease: Review of Management for Primary Care Providers","volume":"97","author":"R Basu","year":"2022","journal-title":"Mayo Clin Proc"},{"issue":"4","key":"pone.0341364.ref017","article-title":"How to Identify Advanced Fibrosis in Adult Patients with Non-Alcoholic Fatty Liver Disease (NAFLD) and Non-Alcoholic Steatohepatitis (NASH) Using Ultrasound Elastography-A Review of the Literature and Proposed Multistep Approach","volume":"13","author":"MG Taru","year":"2023","journal-title":"Diagnostics (Basel)"},{"issue":"15","key":"pone.0341364.ref018","doi-asserted-by":"crossref","first-page":"1287","DOI":"10.1001\/jama.2024.1447","article-title":"Vibration-Controlled Transient Elastography Scores to Predict Liver-Related Events in Steatotic Liver Disease","volume":"331","author":"H Lin","year":"2024","journal-title":"JAMA"},{"issue":"1","key":"pone.0341364.ref019","doi-asserted-by":"crossref","DOI":"10.1016\/j.cgh.2018.04.043","article-title":"Vibration-Controlled Transient Elastography to Assess Fibrosis and Steatosis in Patients With Nonalcoholic Fatty Liver Disease","volume":"17","author":"MS Siddiqui","year":"2019","journal-title":"Clin Gastroenterol Hepatol"},{"issue":"3","key":"pone.0341364.ref020","doi-asserted-by":"crossref","first-page":"659","DOI":"10.1016\/j.jhep.2021.05.025","article-title":"EASL Clinical Practice Guidelines on non-invasive tests for evaluation of liver disease severity and prognosis - 2021 update","volume":"75","author":"European Association for the Study of the Liver","year":"2021","journal-title":"J Hepatol"},{"issue":"2","key":"pone.0341364.ref021","doi-asserted-by":"crossref","first-page":"154","DOI":"10.5005\/jp-journals-10018-1189","article-title":"Nonalcoholic Fatty Liver Disease in South Asia","volume":"6","author":"GK Pati","year":"2016","journal-title":"Euroasian J Hepatogastroenterol"},{"issue":"1","key":"pone.0341364.ref022","doi-asserted-by":"crossref","first-page":"69","DOI":"10.5005\/jp-journals-10018-1263","article-title":"Nonalcoholic fatty liver disease: identifying the disease burden in Sri Lanka","volume":"8","author":"AS Dassanayake","year":"2018","journal-title":"Euroasian J Hepatogastroenterol"},{"issue":"1","key":"pone.0341364.ref023","doi-asserted-by":"crossref","first-page":"246","DOI":"10.1016\/j.dsx.2018.09.002","article-title":"Prevalence and associations of non-alcoholic fatty liver disease (NAFLD) in Sri Lankan patients with type 2 diabetes: A single center study","volume":"13","author":"HMM Herath","year":"2019","journal-title":"Diabetes Metab Syndr"},{"issue":"1","key":"pone.0341364.ref024","article-title":"Prevalence of diabetes and pre-diabetes in Sri Lanka: a new global hotspot-estimates from the Sri Lanka Health and Ageing Survey 2018\/2019","volume":"11","author":"RP Rannan-Eliya","year":"2023","journal-title":"BMJ Open Diabetes Res Care"},{"key":"pone.0341364.ref025","doi-asserted-by":"crossref","first-page":"2046428","DOI":"10.1155\/2019\/2046428","article-title":"High Prevalence of Overweight\/Obesity in Urban Sri Lanka: Findings from the Colombo Urban Study","volume":"2019","author":"N Somasundaram","year":"2019","journal-title":"J Diabetes Res"},{"issue":"1","key":"pone.0341364.ref026","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2022-063959","article-title":"Identification of patients with type 2 diabetes with non-alcoholic fatty liver disease who are at increased risk of progressing to advanced fibrosis: a cross-sectional study","volume":"13","author":"C Mettananda","year":"2023","journal-title":"BMJ Open"},{"issue":"1","key":"pone.0341364.ref027","doi-asserted-by":"crossref","first-page":"14","DOI":"10.2337\/cd21-as01","article-title":"Standards of Medical Care in Diabetes-2021 Abridged for Primary Care Providers","volume":"39","author":"American Diabetes Association","year":"2021","journal-title":"Clin Diabetes"},{"issue":"3","key":"pone.0341364.ref028","doi-asserted-by":"crossref","DOI":"10.1002\/hep.21334","article-title":"FIB-4: a simple, inexpensive and accurate marker of fibrosis in HCV-infected patients","volume":"44","author":"A Vallet-Pichard","year":"2006","journal-title":"Hepatology"},{"issue":"23","key":"pone.0341364.ref029","article-title":"Accuracy of FibroScan in analysis of liver fibrosis in patients with concomitant chronic Hepatitis B and nonalcoholic fatty liver disease","volume":"99","author":"Q Li","year":"2020","journal-title":"Medicine (Baltimore)"},{"key":"pone.0341364.ref030","unstructured":"Shreffler JHM. Diagnostic testing accuracy: sensitivity, specificity, predictive values and likelihood ratios. https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK557491\/"},{"issue":"11","key":"pone.0341364.ref031","doi-asserted-by":"crossref","first-page":"666","DOI":"10.1038\/nrgastro.2013.175","article-title":"Noninvasive evaluation of NAFLD","volume":"10","author":"L Castera","year":"2013","journal-title":"Nat Rev Gastroenterol Hepatol"},{"issue":"10258","key":"pone.0341364.ref032","doi-asserted-by":"crossref","first-page":"1204","DOI":"10.1016\/S0140-6736(20)30925-9","article-title":"Global burden of 369 diseases and injuries in 204 countries and territories, 1990\u20132019: a systematic analysis for the Global Burden of Disease Study 2019","volume":"396","author":"T Vos","year":"2020","journal-title":"The Lancet"},{"issue":"1","key":"pone.0341364.ref033","doi-asserted-by":"crossref","first-page":"216","DOI":"10.1016\/j.jhep.2019.12.025","article-title":"FIB-4 cut-off of 1.3 may be inappropriate in a primary care referral pathway for patients with non-alcoholic fatty liver disease","volume":"73","author":"S Shah","year":"2020","journal-title":"J Hepatol"},{"issue":"3","key":"pone.0341364.ref034","doi-asserted-by":"crossref","first-page":"263","DOI":"10.3803\/EnM.2015.30.3.263","article-title":"Diabetes in Asians","volume":"30","author":"EJ Rhee","year":"2015","journal-title":"Endocrinol Metab (Seoul)"},{"issue":"1","key":"pone.0341364.ref035","doi-asserted-by":"crossref","first-page":"64","DOI":"10.1111\/nyas.12098","article-title":"Type 2 diabetes in East Asians: similarities and differences with populations in Europe and the United States","volume":"1281","author":"RCW Ma","year":"2013","journal-title":"Ann N Y Acad Sci"},{"key":"pone.0341364.ref036","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.ypmed.2014.04.010","article-title":"Using appropriate body mass index cut points for overweight and obesity among Asian Americans","volume":"65","author":"J Jih","year":"2014","journal-title":"Prev Med"},{"issue":"9403","key":"pone.0341364.ref037","doi-asserted-by":"crossref","first-page":"157","DOI":"10.1016\/S0140-6736(03)15268-3","article-title":"Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies","volume":"363","author":"WHO Expert Consultation","year":"2004","journal-title":"Lancet"},{"issue":"1","key":"pone.0341364.ref038","doi-asserted-by":"crossref","first-page":"70","DOI":"10.1111\/jgh.13857","article-title":"Asia-Pacific Working Party on Non-alcoholic Fatty Liver Disease guidelines 2017-Part 1: Definition, risk factors and assessment","volume":"33","author":"VW-S Wong","year":"2018","journal-title":"J Gastroenterol Hepatol"},{"issue":"2","key":"pone.0341364.ref039","doi-asserted-by":"crossref","first-page":"158","DOI":"10.1002\/hep4.1618","article-title":"Nonalcoholic Fatty Liver Disease Screening in Type 2 Diabetes Mellitus Patients in the Primary Care Setting","volume":"5","author":"J Vieira Barbosa","year":"2020","journal-title":"Hepatol Commun"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0341364","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,6]],"date-time":"2026-02-06T18:32:36Z","timestamp":1770402756000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0341364"}},"subtitle":[],"editor":[{"given":"Sophia Eugenia","family":"Mart\u00ednez-V\u00e1zquez","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,2,6]]},"references-count":39,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026,2,6]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0341364","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,6]]}}}