{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,11]],"date-time":"2026-09-11T15:34:04Z","timestamp":1789140844111,"version":"build-2803163510"},"reference-count":54,"publisher":"MDPI AG","issue":"5","license":[{"start":{"date-parts":[[2026,3,1]],"date-time":"2026-03-01T00:00:00Z","timestamp":1772323200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>Background: Metabolic dysfunction-associated steatotic liver disease (MASLD), previously known as non-alcoholic fatty liver disease (NAFLD), is increasingly prevalent in children. However, reliable noninvasive diagnostic tools remain limited. The hepatorenal index (HRI) has been proposed as a quantitative ultrasound method to assess hepatic steatosis. This study aims to evaluate the diagnostic accuracy of HRI in detecting pediatric MASLD. Methods: A systematic review and meta-analysis were conducted on 13 September 2025, following PRISMA-DTA guidelines, with the protocol registered in PROSPERO (CRD420251146939). MEDLINE, PubMed, Cochrane Library, ScienceDirect, and Google Scholar were searched. Studies that assessed HRI against reference standards (MRI-PDFF or liver biopsy) in pediatric MASLD were included. Pooled diagnostic parameters were estimated using a bivariate random-effects model, with heterogeneity evaluated by I2 statistics and publication bias by funnel plot asymmetry. Results: Four studies involving 194 pediatric patients (47.9% MASLD), mostly male (57.7%), met the inclusion criteria. The suggested HRI cut-off varies from \u22651.215 to 1.99. The pooled sensitivity and specificity were 90% (95% CI 70\u201397) and 84% (95% CI 73\u201392), respectively, with an AUC of 0.91 (95% CI 0.88\u20130.93). Positive and negative likelihood ratios were 6 and 0.12, corresponding to post-test probabilities of 32% and 1%, respectively. No significant publication bias or heterogeneity was detected. Conclusions: Although HRI demonstrates strong diagnostic performance, it currently lacks sufficient discriminatory power to definitively confirm or exclude MASLD in pediatric populations and should therefore be regarded as a supportive rather than definitive diagnostic tool pending further high-quality validation studies.<\/jats:p>","DOI":"10.3390\/diagnostics16050729","type":"journal-article","created":{"date-parts":[[2026,3,3]],"date-time":"2026-03-03T15:22:21Z","timestamp":1772551341000},"page":"729","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["A Systematic Review and Meta-Analysis on the Diagnostic Test Accuracy of Hepatorenal Index in Pediatric Metabolic Dysfunction-Associated Steatotic Liver Disease"],"prefix":"10.3390","volume":"16","author":[{"given":"Ratna","family":"Sutanto","sequence":"first","affiliation":[{"name":"Pediatric Imaging Division, Department of Radiology, Faculty of Medicine, Universitas Pelita Harapan, Tangerang 15811, Indonesia"},{"name":"Radiology Department, Faculty of Medicine, Universitas Pelita Harapan, Tangerang 15811, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aristya Dewi","family":"Pratiwi","sequence":"additional","affiliation":[{"name":"Radiology Department, Faculty of Medicine, Universitas Pelita Harapan, Tangerang 15811, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-6495-3025","authenticated-orcid":false,"given":"Callistus Bruce Henfry","family":"Sulay","sequence":"additional","affiliation":[{"name":"Radiology Department, Faculty of Medicine, Universitas Pelita Harapan, Tangerang 15811, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6439-6265","authenticated-orcid":false,"given":"Gilbert Sterling","family":"Octavius","sequence":"additional","affiliation":[{"name":"Radiology Department, Faculty of Medicine, Universitas Pelita Harapan, Tangerang 15811, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,3,1]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Anderson, E.L., Howe, L.D., Jones, H.E., Higgins, J.P., Lawlor, D.A., and Fraser, A. (2015). The Prevalence of Non-Alcoholic Fatty Liver Disease in Children and Adolescents: A Systematic Review and Meta-Analysis. PLoS ONE, 10.","DOI":"10.1371\/journal.pone.0140908"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1542","DOI":"10.1016\/j.jhep.2023.06.003","article-title":"A multisociety Delphi consensus statement on new fatty liver disease nomenclature","volume":"79","author":"Rinella","year":"2023","journal-title":"J. Hepatol."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"European Society for Pediatric Gastroenterology HaNEEAftSotLENASfPG, Hepatology, and Nutrition (NASPGHAN), Latin-American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (LASPGHAN), Asian Pan-Pacific Society for Pediatric Gastroenterology, Hepatology and Nutrition (APPSPGHAN), Pan Arab Society for Pediatric Gastroenterology and Nutrition (PASPGHAN), Commonwealth Association of Paediatric Gastroenterology & Nutrition (CAPGAN), and Federation of International Societies of Pediatric Hepatology, Gastroenterology and Nutrition (FISPGHAN) (2024). Paediatric steatotic liver disease has unique characteristics: A multisociety statement endorsing the new nomenclature. J. Pediatr. Gastroenterol. Nutr., 78, 1190\u20131196.","DOI":"10.1002\/jpn3.12156"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"S164","DOI":"10.1542\/peds.2007-2329C","article-title":"Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report","volume":"120","author":"Barlow","year":"2007","journal-title":"Pediatrics"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"170","DOI":"10.1001\/jamapediatrics.2014.2702","article-title":"Nonalcoholic fatty liver disease: A challenge for pediatricians","volume":"169","author":"Nobili","year":"2015","journal-title":"JAMA Pediatr."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"863","DOI":"10.1007\/s00431-019-03362-3","article-title":"Comparison of diagnostic accuracy of screening tests ALT and ultrasound for pediatric non-alcoholic fatty liver disease","volume":"178","author":"Draijer","year":"2019","journal-title":"Eur. J. Pediatr."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"504","DOI":"10.1016\/j.clinimag.2012.07.011","article-title":"Importance of the liver ultrasound scores in pubertal obese children with nonalcoholic fatty liver disease","volume":"37","author":"Akcam","year":"2013","journal-title":"Clin. Imaging"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"190","DOI":"10.1097\/MPG.0b013e31821b4b61","article-title":"Ultrasonographic quantitative estimation of hepatic steatosis in children With NAFLD","volume":"53","author":"Shannon","year":"2011","journal-title":"J. Pediatr. Gastroenterol. Nutr."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"e223146","DOI":"10.1148\/radiol.223146","article-title":"The Future Is Beyond Bright: The Evolving Role of Quantitative US for Fatty Liver Disease","volume":"309","author":"Ozturk","year":"2023","journal-title":"Radiology"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"765","DOI":"10.1016\/j.cgh.2013.09.050","article-title":"Evidence and recommendations for imaging liver fat in children, based on systematic review","volume":"12","author":"Awai","year":"2014","journal-title":"Clin. Gastroenterol. Hepatol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"909","DOI":"10.2214\/AJR.07.4016","article-title":"Diagnostic value of a computerized hepatorenal index for sonographic quantification of liver steatosis","volume":"192","author":"Webb","year":"2009","journal-title":"AJR Am. J. Roentgenol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"m2632","DOI":"10.1136\/bmj.m2632","article-title":"Preferred reporting items for systematic review and meta-analysis of diagnostic test accuracy studies (PRISMA-DTA): Explanation, elaboration, and checklist","volume":"370","author":"Salameh","year":"2020","journal-title":"BMJ"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"319","DOI":"10.1097\/MPG.0000000000001482","article-title":"NASPGHAN Clinical Practice Guideline for the Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease in Children: Recommendations from the Expert Committee on NAFLD (ECON) and the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN)","volume":"64","author":"Vos","year":"2017","journal-title":"J. Pediatr. Gastroenterol. Nutr."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"827","DOI":"10.1007\/s12098-015-1848-6","article-title":"Newer Diagnostic Tests for Pulmonary Tuberculosis in Children","volume":"82","author":"Triasih","year":"2015","journal-title":"Indian. J. Pediatr."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"691","DOI":"10.1002\/jmri.29756","article-title":"MR and Ultrasound for Liver Fat Assessment in Children: Techniques and Supporting Evidence","volume":"62","author":"Serai","year":"2025","journal-title":"J. Magn. Reson. Imaging"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"602","DOI":"10.1016\/j.jclinepi.2010.07.006","article-title":"Inclusion of methodological filters in searches for diagnostic test accuracy studies misses relevant studies","volume":"64","author":"Whiting","year":"2011","journal-title":"J. Clin. Epidemiol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"210","DOI":"10.1186\/s13643-016-0384-4","article-title":"Rayyan\u2014A web and mobile app for systematic reviews","volume":"5","author":"Ouzzani","year":"2016","journal-title":"Syst. Rev."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"529","DOI":"10.7326\/0003-4819-155-8-201110180-00009","article-title":"QUADAS-2: A revised tool for the quality assessment of diagnostic accuracy studies","volume":"155","author":"Whiting","year":"2011","journal-title":"Ann. Intern. Med."},{"key":"ref_19","unstructured":"MedCalc Software Ltd. (2023, December 29). Diagnostic Test Evaluation Calculator (Version 22.016). Available online: https:\/\/www.medcalc.org\/calc\/diagnostic_test.php."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"982","DOI":"10.1016\/j.jclinepi.2005.02.022","article-title":"Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews","volume":"58","author":"Reitsma","year":"2005","journal-title":"J. Clin. Epidemiol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"2865","DOI":"10.1002\/sim.942","article-title":"A hierarchical regression approach to meta-analysis of diagnostic test accuracy evaluations","volume":"20","author":"Rutter","year":"2001","journal-title":"Stat. Med."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"3","DOI":"10.4078\/jrd.2018.25.1.3","article-title":"Overview of the Process of Conducting Meta-analyses of the Diagnostic Test Accuracy","volume":"25","author":"Lee","year":"2018","journal-title":"J. Rheum. Dis."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1539","DOI":"10.1002\/sim.1186","article-title":"Quantifying heterogeneity in a meta-analysis","volume":"21","author":"Higgins","year":"2002","journal-title":"Stat. Med."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1258\/096914103321610806","article-title":"A likelihood ratio approach to meta-analysis of diagnostic studies","volume":"10","author":"Stengel","year":"2003","journal-title":"J. Med. Screen."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"3258","DOI":"10.1002\/sim.2812","article-title":"Prevalence-dependent diagnostic accuracy measures","volume":"26","author":"Li","year":"2007","journal-title":"Stat. Med."},{"key":"ref_26","first-page":"605","article-title":"MIDAS: Stata module for meta-analytical integration of diagnostic test accuracy studies","volume":"12","author":"Dwamena","year":"2007","journal-title":"Stata J."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1306","DOI":"10.1007\/s00247-022-05313-x","article-title":"Diagnostic performance of ultrasound hepatorenal index for the diagnosis of hepatic steatosis in children","volume":"52","author":"Frankland","year":"2022","journal-title":"Pediatr. Radiol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1653","DOI":"10.1007\/s00247-024-06021-4","article-title":"Ultrasound-estimated hepatorenal index: Diagnostic performance and interobserver agreement for pediatric liver fat quantification","volume":"54","author":"Hajibonabi","year":"2024","journal-title":"Pediatr. Radiol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"2458","DOI":"10.1007\/s00247-023-05749-9","article-title":"Quantitative ultrasound fatty liver evaluation in a pediatric population: Comparison with magnetic resonance imaging of liver proton density fat fraction","volume":"53","author":"Polti","year":"2023","journal-title":"Pediatr. Radiol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"996","DOI":"10.2214\/AJR.20.24874","article-title":"Liver Fat Quantification by Ultrasound in Children: A Prospective Study","volume":"217","author":"Rubesova","year":"2021","journal-title":"AJR Am. J. Roentgenol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"2221","DOI":"10.1007\/s00247-023-05729-z","article-title":"Prevalence of incidental sonographic findings of hepatic steatosis in children under 4 years of age","volume":"53","author":"Green","year":"2023","journal-title":"Pediatr. Radiol."},{"key":"ref_32","first-page":"3","article-title":"Noninvasive quantitative ultrasound fatty liver evaluation of hepato-renal index in pediatric patients using 3D-slicer","volume":"11","author":"Battaglia","year":"2024","journal-title":"J. Med. Imaging Interv. Radiol."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"de Boom, F., Talib, A., Roebroek, Y.G.M., Paulus, G.F., Koek, G.H., Robben, S.G.F., Winkens, B., Bouvy, N.D., and van Heurn, L.W.E. (2024). Non-Invasive Assessment of Metabolic Dysfunction-Associated Steatotic Liver Disease in Adolescents with Severe Obesity; Patient Characteristics and Association with Leptin-A Cross-Sectional Overview of Baseline Data from a RCT. Children, 11.","DOI":"10.3390\/children11080965"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"679","DOI":"10.1002\/jpn3.70142","article-title":"Sonographic evidence of hepatic steatosis is highly prevalent in at-risk children under 4 years of age","volume":"81","author":"Glenn","year":"2025","journal-title":"J. Pediatr. Gastroenterol. Nutr."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"2653","DOI":"10.1007\/s11325-024-03149-3","article-title":"Elastography as a non-invasive method of screening non-alcoholic fatty liver disease in the adult phenotype of paediatric obstructive sleep apnoea","volume":"28","author":"Durdikova","year":"2024","journal-title":"Sleep Breath."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"W201","DOI":"10.2214\/AJR.08.2061","article-title":"Computer-assisted ultrasound analysis of liver echogenicity in obese and normal-weight children","volume":"192","author":"Soder","year":"2009","journal-title":"AJR Am. J. Roentgenol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"660","DOI":"10.1148\/radiol.212995","article-title":"Comparison of Quantitative Liver US and MRI in Patients with Liver Disease","volume":"304","author":"Alves","year":"2022","journal-title":"Radiology"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"2395","DOI":"10.1002\/jum.14598","article-title":"A Practical Approach to Quantitative Grayscale Ultrasound Analysis of Hepatic Steatosis in Pediatric Patients Using a Picture Archiving and Communication System-Based Tool","volume":"37","author":"Joyce","year":"2018","journal-title":"J. Ultrasound Med."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"225","DOI":"10.1590\/0100-3984.2014.0074","article-title":"Accuracy of computer-aided ultrasound as compared with magnetic resonance imaging in the evaluation of nonalcoholic fatty liver disease in obese and eutrophic adolescents","volume":"48","author":"Soder","year":"2015","journal-title":"Radiol. Bras."},{"key":"ref_40","first-page":"46","article-title":"Comparison of Ultrasound-Based Techniques and Magnetic Resonance Imaging Proton Density Fat Fraction in Measuring the Amount of Hepatic Fat in Children with Hepatosteatosis","volume":"40","author":"Bozbeyoglu","year":"2025","journal-title":"Medeni. Med. J."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"164","DOI":"10.1002\/jcu.70006","article-title":"Reliability of Ultrasonic Hepatorenal Indices in Assessing Hepatic Steatosis: A Systematic Review and Meta-Analysis","volume":"54","author":"Wang","year":"2025","journal-title":"J. Clin. Ultrasound"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"487","DOI":"10.1002\/jum.15991","article-title":"Hepatorenal Index by B-Mode Ratio Versus Imaging and Fatty Liver Index to Diagnose Steatosis in Alcohol-Related and Nonalcoholic Fatty Liver Disease","volume":"42","author":"Kjaergaard","year":"2023","journal-title":"J. Ultrasound Med."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"e00681","DOI":"10.1097\/RUQ.0000000000000681","article-title":"Revisiting the Hepatorenal Index in the Quantification of Hepatic Steatosis: How it is done and the utility","volume":"40","author":"Duncan","year":"2024","journal-title":"Ultrasound Q."},{"key":"ref_44","doi-asserted-by":"crossref","unstructured":"Johnson, S.I., Fort, D., Shortt, K.J., Therapondos, G., Galliano, G.E., Nguyen, T., and Bluth, E.I. (2021). Ultrasound Stratification of Hepatic Steatosis Using Hepatorenal Index. Diagnostics, 11.","DOI":"10.3390\/diagnostics11081443"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1887","DOI":"10.1002\/hep.27666","article-title":"Magnetic resonance imaging and liver histology as biomarkers of hepatic steatosis in children with nonalcoholic fatty liver disease","volume":"61","author":"Schwimmer","year":"2015","journal-title":"Hepatology"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"1093","DOI":"10.1002\/jum.16669","article-title":"The Effect of Backscatter Anisotropy in Assessing Hepatic Steatosis Using Ultrasound Hepatorenal Index","volume":"44","author":"Gao","year":"2025","journal-title":"J. Ultrasound Med."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"212","DOI":"10.1007\/BF02388162","article-title":"Sonographic renal parameters as related to age","volume":"17","author":"Vade","year":"1987","journal-title":"Pediatr. Radiol."},{"key":"ref_48","doi-asserted-by":"crossref","unstructured":"Isaksen, V.T., Larsen, M.A., Goll, R., Florholmen, J.R., and Paulssen, E.J. (2016). Hepatic steatosis, detected by hepatorenal index in ultrasonography, as a predictor of insulin resistance in obese subjects. BMC Obes., 3.","DOI":"10.1186\/s40608-016-0118-0"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"3159","DOI":"10.1002\/jum.16102","article-title":"A Standardized Approach for MRI-PDFF is Necessary in the Assessment of Diagnostic Performances of the Ultrasound-Based Hepatic Fat Quantification Tools","volume":"41","year":"2022","journal-title":"J. Ultrasound Med."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"1051","DOI":"10.7863\/ultra.34.6.1051","article-title":"Improved method for calculating hepatic steatosis using the hepatorenal index","volume":"34","author":"Shiralkar","year":"2015","journal-title":"J. Ultrasound Med."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"546","DOI":"10.3345\/cep.2025.00157","article-title":"Metabolic dysfunction-associated steatotic liver disease in children: A practical update based on Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition (ISPGHAN) 2024 guidelines","volume":"68","author":"Agrawal","year":"2025","journal-title":"Clin. Exp. Pediatr."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"477","DOI":"10.3345\/cep.2022.01445","article-title":"Inferior vena cava to aorta ratio in dehydrated pediatric patients: A systematic review and meta-analysis","volume":"66","author":"Octavius","year":"2023","journal-title":"Clin. Exp. Pediatr."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"200","DOI":"10.1002\/cld.994","article-title":"Imaging Modalities in Pediatric NAFLD","volume":"17","author":"Serai","year":"2021","journal-title":"Clin. Liver Dis."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 statement: An updated guideline for reporting systematic reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"}],"container-title":["Diagnostics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4418\/16\/5\/729\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,3]],"date-time":"2026-03-03T15:45:48Z","timestamp":1772552748000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4418\/16\/5\/729"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,1]]},"references-count":54,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2026,3]]}},"alternative-id":["diagnostics16050729"],"URL":"https:\/\/doi.org\/10.3390\/diagnostics16050729","relation":{},"ISSN":["2075-4418"],"issn-type":[{"value":"2075-4418","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,1]]}}}