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Life sciences · Review
Diabetes Obesity and Metabolism · September 17, 2026
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ABSTRACT Aims Adults with obesity are at increased risk of metabolic dysfunction‐associated steatotic liver disease (MASLD)‐related fibrosis, but the diagnostic performance of non‐invasive tests (NITs) in this population remains uncertain. This meta‐analysis evaluated NITs for detecting significant (≥F2) and advanced (≥F3) fibrosis in adults with obesity and MASLD. Materials and Methods PubMed/MEDLINE, Embase, Web of Science and the Cochrane Library were searched from inception to 1 December 2025. Eligible studies enrolled adults with obesity (BMI ≥ 30 kg/m 2 ) and MASLD, compared an NIT with liver biopsy, and provided data to estimate sensitivity and specificity. Pooled estimates were derived using bivariate random‐effects models; HSROC curves were generated for each test and fibrosis threshold. Results Twenty‐seven studies including 5034 participants were included. Mean age was 40.6 ± 11.4 years and mean BMI was 43.3 ± 7.1 kg/m 2. For significant fibrosis (≥F2), vibration‐controlled transient elastography (VCTE) showed a sensitivity of 0.64 (95% CI, 0.49–0.77) and specificity of 0.77 (95% CI, 0.66–0.85), with a median threshold of 7.95 kPa (IQR, 7.60–12.00). FIB‐4 showed broadly comparable performance, with a sensitivity of 0.65 (95% CI, 0.53–0.75) and specificity of 0.77 (95% CI, 0.64–0.86). For advanced fibrosis (≥F3), VCTE showed a sensitivity of 0.77 (95% CI, 0.67–0.85) and specificity of 0.84 (95% CI, 0.76–0.90), with a median threshold of 10.73 kPa (IQR, 8.15–12.80). Serum‐based tests showed more variable operating characteristics. Post hoc threshold analyses showed the expected trade‐off between sensitivity and specificity at lower VCTE cut‐offs. Conclusions In adults with obesity and MASLD, VCTE showed the most consistent diagnostic performance, particularly for advanced fibrosis, whereas serum‐based tests demonstrated more variable operating characteristics. Threshold selection and technical feasibility remain important determinants of performance, highlighting the need for validated obesity‐specific thresholds and diagnostic pathways.