Role of imaging-based biomarkers in NAFLD: Recent advances in clinical application and future research directions

Non-alcoholic fatty liver disease (NAFLD) is a major public health problem afflicting approximately one billion individuals worldwide. Liver biopsy is considered the gold standard for assessment of liver disease severity in patients with NAFLD. However, it is invasive, has high inter-observer variability, and is associated with adverse effects, including pain, infection and, albeit rarely, death. It is also impractical because of the large number of individuals who have NAFLD. Therefore, tools to non-invasively assess disease severity in NAFLD are urgently needed. Over the last two decades, tremendous advances have been made in the assessment of NAFLD by non-invasive imaging. In this review, we will discuss the different non-invasive imaging modalities available to quantify liver fat and liver fibrosis. We will also discuss the limitations of current modalities to detect the progressive form for NAFLD, termed non-alcoholic steatohepatitis. Finally, we will discuss the comparative efficacy of various imaging-based elastographic modalities for detection of advanced fibrosis or cirrhosis, as well as their diagnostic characteristics.