Introduction

As the primary cause of liver-related deaths, cirrhosis is causing a significant amount of morbidity and mortality worldwide and placing a heavy financial strain on healthcare systems. The last step of liver fibrosis progression is cirrhosis; however, because compensated cirrhosis initially manifests asymptomatically, its frequency is neglected. Because of this, many patients with compensated cirrhosis go untreated until they experience the first decompensation episode, which might include encephalopathy, ascites, elevated bilirubin levels, or variceal hemorrhage1. With a 1-year case-fatality rate that can occasionally surpass 80%, the mortality and morbidity rates for this patient group are significantly higher than those for compensated cirrhosis, even though they are typically promptly linked to medical care2.

Currently, alcohol-related liver disease (ALD), metabolic dysfunction-associated steatotic liver disease (MASLD) and chronic hepatitis B (HBV) and C (HCV) infections are the main causes of liver cirrhosis3. Since the etiology of liver cirrhosis is rapidly evolving due to successful antiviral therapies with direct acting antivirals for HCV and viral hepatitis vaccination campaigns for HBV, MASLD has emerged as the leading cause of chronic liver disease (CLD) globally4.

Steatotic liver disease (SLD) was previously divided into two subtypes: ALD and non-alcoholic fatty liver disease (NAFLD), which did not include more than moderate alcohol consumption. More than 80 million individuals in the USA and 38% of the world’s population are thought to have NAFLD, with an estimated 3.3 million of them having advanced fibrosis5. Up to 60% of cirrhosis cases in North America and Europe are caused by alcohol, making it the primary cause of cirrhosis worldwide. Based on the existence of metabolic risk factors and/or heavy alcohol consumption, a new nomenclature was created in 2023 that recognized the spectrum of SLD, including MASLD, metabolic and alcohol-associated liver disease (MetALD), and ALD6,7. A new diagnostic category called MetALD was established because of the terminology change, acknowledging the possibility that both metabolic risk factors and alcohol use may play a role in the onset and severity of chronic liver disease8.

The most recent epidemiological research indicates that Europe appears to have the highest burden of liver disease worldwide and projections for the rise in cases over the next several years are being made. According to EASL HepaHealth study, released in 2018, showed that liver disease-related mortality in Romania accounted for 36.4 per 100,000 people, or 3.75% of all deaths9. The prevalence and severity of the new SLD categories in Europe are not well described by prospective data. The prevalence of SLD ranged from 34.6 to 42.15%, MASLD from 31.1 to 37.7%, and MetALD from 2 to 3.9% according to publications utilizing the NHANES cohort. Also, the prevalence of advanced fibrosis is estimated from 7.6 to 20.86% in MASLD patients, and from 5.9 to 9.5% in MetALD individuals10.

There are currently two methods for noninvasively assessing fibrosis: the first is a biological method that uses serum biomarkers of fibrosis, such as the Fibrosis-4 Index (FIB-4), BARD, Forns, and NAFLD Score, as well as the aspartate aminotransferase (AST)–to-platelet ratio index. This method has a modest diagnostic performance and area under the curve (AUROC) between 0.54 and 0.71 according to Hargstrom et al.11. The second method is a physical method based on liver stiffness measurement (LSM) using transient elastography (TE) with controlled attenuation parameter (CAP) (FibroScan®; Echosens, Paris, France)12. LSM with implemented CAP has a strong diagnostic accuracy to estimate the severity of steatosis and fibrosis. Its usefulness in assessing a broad and seemingly healthy population has been demonstrated in numerous research from Romania, China, Italy, United Kingdom and USA3,13.

However, most of the research on screening for cirrhosis and advanced fibrosis has been conducted in medical institutions, and no data regarding Eastern European vulnerable populations at high risk of developing advanced liver fibrosis is available14. Economically disadvantaged individuals, members of racial and ethnic minorities, children, low-income individuals, the elderly, the homeless, and those suffering from long-term medical illnesses, including serious mental illness, are among the vulnerable groups. They can also comprise people living in rural areas, where access to healthcare services is frequently limited. These people are more vulnerable due to their color, ethnicity, age, gender, and other characteristics like their income, insurance, and lack of a steady provider of care15. Chronic liver disease is significantly more prevalent among low-income and other disadvantaged populations. In addition, the impact of these diseases is more severe among the unemployed, uninsured, and those with only a secondary education16.

To investigate the prevalence of SLD, advanced fibrosis, and cirrhosis, as well as the prevalence of MASLD, MetALD, and ALD using transient elastography, we used a prospective and distinctively well-characterized cohort design in a socioeconomically challenged population from North-Eastern Romania that is characterized by vulnerable socioeconomic conditions like having lower educational attainment and living in rural areas.

Materials and methods

Study design

The present research is a longitudinal prospective study carried out in the Institute of Gastroenterology and Hepatology within the County Emergency Clinical Hospital “St. Spiridon”, between October 2020 and April 2024, in which 571 patients with vulnerable conditions (rural environment or with low educational levels) who had no known chronic liver disease were included to evaluate the prevalence of steatosis, advanced fibrosis and cirrhosis due to ALD, MASLD or chronic viral hepatitis. Low level of education was defined by subjects which had less than primary, primary or lower secondary degree of education. More than that, the low educational level is considered a risk factor for developing MASLD and liver fibrosis among patients in both genders17. North-Eastern region of Romania is known for having vulnerable conditions in several areas, such as increased exposure to risk factors like tobacco use, eating foods high in fat and energy, drinking excessively, not exercising, having a high body mass index (BMI ≥ 25 kg/m2), and having less access to healthcare services (Fig. 1). A clinical suspicion of MASLD or elevated liver enzymes led to the recruitment of participants from general care or colleagues from endocrinology or diabetology department. From October 2020 to April 2024, the study participants received a standardized research visit that included a physical examination, alcohol questionnaires including Alcohol Use Disorder Identification Test (AUDIT) to establish the alcohol consumption, biological and immunological parameters from the laboratory, TE with CAP, and abdominal ultrasound evaluation.

Inclusion criteria are represented by patients over the age of 18 years old, with an absence of a history of chronic liver disease and agree to participate in the study by signing the informed consent. Patients with a history of chronic viral hepatitis (HBV/HCV/HDV) infection or other causes of chronic liver disease (autoimmune hepatitis, Wilson disease, hemochromatosis, HIV co-infection, alcoholic liver disease), pregnancy, cardiac pacemakers, cancer, end-stage renal disease, life expectancy less than five years, presence of ascites or hepatocellular carcinoma at ultrasound examination, aspartate aminotransferase (AST)/alanine aminotransferase (ALT) ≥ 5 times the upper limit of normal, or total bilirubin level ≥ 5 mg/dL due to unreliable or failure TE examination were all excluded. The study activities adhered to the principles outlined in the Declarations of Helsinki and Istanbul. The Ethics Committee of our Institute and the University of Medicine and Pharmacy “Gr. T. Popa”, Iasi, ratified this with approval number 174. All the methods were performed in accordance with EASL guidelines on non-invasive tests for evaluation of liver disease severity and prognosis.

Fig. 1
figure 1

Study flow chart. A total of 51 vulnerable patients from North-Eastern Romania were excluded from the study.

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Clinical evaluation and laboratory tests

All patients participated in a standardized research visit that included a comprehensive medical and medication history, physical examination with vital signs, height, weight, and anthropometric measurements. The World Health Organization established the cutoff values for lean (≥ 18.5 kg/m2), overweight (≥ 25 kg/m2), and obese (> 30 kg/m2) individuals. Abdominal obesity is defined as a waist circumference of 80 cm or greater for women and 94 cm or greater for men. This measurement is often utilized as a proxy for assessing visceral adiposity18. A fasting blood draw was conducted, encompassing a complete blood count, complete metabolic profile, iron studies, lipid panel, and immunological panel, which included hepatitis B surface antigen, anti–hepatitis C virus and anti–hepatitis D virus antibodies. Additionally, serological biomarkers of liver fibrosis were assessed, including aspartate aminotransferase [AST]-to-platelet ratio index [APRI], fibrosis-4 index (FIB-4), NAFLD (NFS) score, Agile 3+, and Agile 4 + scores. Alcohol use was evaluated through standardized validated questionnaires, such as the Alcohol Use Disorder Identification Test (AUDIT-C) for current heavy drinking and/or active alcohol abuse or dependence. Recent scientific recommendations indicate that the threshold for excessive alcohol intake is 20 g per day for women and 30 g per day for men9,10.

Transient elastography with CAP measurements

Liver stiffness was quantified using TE, and liver steatosis was assessed using CAP, both performed with FibroScan (Echosens, Paris, France). Examinations were conducted by a qualified technician with the subject in a supine position and the right upper extremity fully abducted. Liver stiffness measurements (LSM) were acquired from the right liver lobe through intercostal scanning, adhering to a minimum fasting duration of four hours as established by guidelines19. The FibroScan system automatically conducted a minimum of 10 valid measurements during patient breath holding. Examinations were included in the final analysis only if the interquartile range/median ratio did not exceed 30% (interquartile range/median ≤ 30%). All participants received initial scanning using the M probe (3.5 MHz). Participants underwent scanning with the XL probe (2.5 MHz) when the initial assessment revealed a distance greater than 25 mm between the skin and liver capsule. LSM results were quantified in kilopascals (kPa), with values ranging from 1.5 to 75 kPa. Liver fibrosis stages were categorized using the following cutoff values: significant fibrosis at ≥ 8.0 kPa, advanced fibrosis at ≥ 9.6 kPa, and cirrhosis at ≥ 13 kPa. CAP measurements were recorded in decibels/m, spanning from 100 to 400 dB/m, with steatosis degrees differentiated by the following cutoffs: mild steatosis at ≥ 274 dB/m, moderate steatosis at ≥ 290 dB/m, and severe steatosis at ≥ 302 dB/m12.

Abdominal ultrasound examination

An abdominal ultrasound was conducted following TE tests by an experienced physician specializing in liver imaging, who was blinded to all clinical data. The procedure utilized a 3.5–5 MHz convex probe and a high-resolution B-mode scanner (Supersonic Aixplorer MACH 30). B-mode images were uploaded to a personal computer to determine the hepatorenal index by comparing the luminance of two regions of interest located in liver segment 6 and the right kidney cortex, utilizing ImageJ software (National Institutes of Health, Bethesda, MD, USA; version 1.54f; https://imagej.nih.gov/ij/). Patients were classified as having hepatic steatosis or not based on ultrasound findings indicative of the condition, including increased echogenicity of the liver parenchyma relative to the right kidney cortex, diminished visualization of the diaphragm, intrahepatic vessel borders, and the posterior surface of the right hepatic lobe, as well as a hepatorenal index value exceeding 1.2820.

Statistical analysis

The statistical variables were represented as numerical values, whilst the continuous variables were denoted as mean ± SD. The distribution study utilized the Kolmogorov-Smirnov test, whilst parametric tests, including the t-test and ANOVA, were employed to assess differences among numerical variables exhibiting normal distribution. A significance test, typically the t-test, is employed to ascertain the connection between two variables and its statistical significance. This test aims to ascertain if the observed correlation coefficient significantly deviates from zero, indicating a lack of linear relationship in the population. The two-tailed values of α < 0.05 (p < 0.05) were deemed statistically significant. All statistical parameters were obtained using IBM SPSS, Version 22.0 (IBM SPSS Inc.).

Results

General characteristics of the vulnerable population

571 patients who satisfied the admission criteria were included in the final analysis, from which 402 subjects (70.4%) lived in rural environment area and 169 (29.6%) had low level of education (primary and lower secondary degree). The mean age of these patients was 55.87 ± 13.84 years, and 301 (52.7%) of them were male. Their mean waist circumference was 95.69 ± 11.71 cm, and their mean BMI was 28.17 ± 4.73 kg/m. Consequently, we discovered that 183 (32.05%) participants were overweight and that the prevalence of obesity was 39.4% of the entire cohort. Moreover, 182 (31.2%) had hypertension, and 140 (24.5%) had type 2 diabetes mellitus from their medical history. Additionally, it was discovered that almost one-third (37.3%) of vulnerable individuals had metabolic syndrome. According to the AUDIT-C questionnaire, more than half of the population study have no risk of alcohol consumption (54.3%), and 17.3% of subjects had high risk of ethanol ingestion and were diagnosed with ALD. The standard M-probe was used to test 85.3% of the 571 screened subjects, and the median CAP and LSM values were 265.99 ± 62.8 dB/m and 10.41 ± 6.6 kPa, respectively. According to CAP measurements 194 (34.3%) of them had no steatosis, 168 (29.4%) had mild steatosis, 70 (12%) had moderate steatosis, and approximately one-quarter of examined patients had severe steatosis (24.5%). From TE evaluations, we also found that 208 (36.4%) of the participants had no fibrosis, 164 (28.7%) had mild fibrosis, 50 (8.8%) had significant fibrosis, 57 (10%) had significant fibrosis and 92 (16.1%) of the subjects were diagnosed with cirrhosis (Table 1).

Table 1 Baseline characteristics of the overall cohort.
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Prevalence of liver fibrosis etiology

Among vulnerable individuals, we found that one-quarter of the investigated subjects have no chronic liver disease (25.2%), 99 (17.3%) were categorised with ALD, 48 (8.4%) were found with HBV-infection, 35 (6.1%) were found with HCV-infection, 41 (7.2%) were categorised with MetALD, and more than one-third of the vulnerable patients were categorised with MASLD (35.7%) (Fig. 2).

Fig. 2
figure 2

Prevalence of liver fibrosis etiology. Abbreviations: ALD, alcohol-related liver disease; MASLD, metabolic dysfunction-associated steatotic liver disease; MetALD, metabolic dysfunction and alcohol associated steatotic liver disease; HCV-chronic hepatitis C; HBV-chronic hepatitis B.

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Compared with other subcategories of liver fibrosis, MASLD participants had a higher BMI (29.74 ± 5.04 kg/m2) and a higher percentage of obesity (47.05%), and presence of diabetes mellitus (31.9%). They also had an important prevalence of individuals with hypertension (40.6%), and higher mean of triglycerides (187.24 ± 61.08 mg/dl), total cholesterol (228.09 ± 44.71 mg/dl), fasting glucose (118.56 ± 40.12 mg/dl) and HbA1c (6.2 ± 0.74%) levels, but had lower mean values of AST (34.76 ± 20.62 U/L) and ALT (36.11 ± 22.67 U/L). Moreover, MASLD patients had lower values of FIB-4 index (1.58 ± 1.06), APRI-score (0.55 ± 0.28), NFS-score (-1.48 ± 1.18), Agile3+-score (0.36 ± 0.26), Agile4-score (0.1 ± 0.04) and LSM measurements (8.24 ± 5.16 kPa) compared with the other subcategories of chronic liver disease. Instead, individuals with ALD had the lowest values of platelets count (209.34 ± 66.52 G/L) and albumin levels (4.12 ± 0.37 g/dl), but the highest values of total bilirubin (1.6 ± 0.81 mg/dl), INR (1.14 ± 0.18), ALT (82.14 ± 51.22 U/L) and AST (91.44 ± 44.52) levels. Also, they had the higher prevalence of hypertension (47.5%), and according to TE examinations participant with ALD had the higher mean CAP and LSM values, of 328 ± 58.43 dB/m and 15.51 ± 9.24 kPa, respectively. The non-invasive scores for liver fibrosis such as FIB-4 index (1.94 ± 1.21), APRI-score (0.86 ± 0.58), NFS-score (-0.86 ± 1.56), Agile3+-score (0.54 ± 0.32) and Agile4-score (0.26 ± 0.18) presents higher values in group of ALD patients. Moreover, in the group of patients with viral hepatitis we found that the prevalence of low-to-moderate alcohol risk consumption affects 22.9% of the individuals with HBV-infection and 25.8% of the participant diagnosed with HCV-infection. Therefore, in these two subgroups we found elevated values of LSM, from 12.04 ± 7.14 kPa in HBV-infection individuals, to 13.16 ± 7.66 kPa in HCV-infection subcategory. Participants categorized in MetALD group had the highest prevalence of metabolic syndrome (63.4%), but the lowest mean LSM values (11.51 ± 6.8 kPa) in comparison with the other patients with chronic liver disease. Instead, individuals with no CLD have the lowest rates of diabetes (16.5%), metabolic syndrome (11.8%) and hypertension (6.3%), but approximately one-third of them had obesity (30.5%), and 38.2% have a low-to-moderate risk of alcohol consumption (Table 2).

Table 2 General characteristics of the patients according to liver fibrosis etiology.
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Subgroups of people with CLD differed significantly (p-value) in the prevalence of cirrhosis and advanced fibrosis. Therefore, the MASLD group of patients had the lowest prevalence of cirrhosis and advanced fibrosis, at 8.8% and 6.4%, respectively. In the group of viral hepatitis, more than half of patients (52.9%) with HBV-infection and HCV-infection (57.1%) had been diagnosed with advanced fibrosis or cirrhosis. Furthermore, the highest prevalence of patients with cirrhosis was found in MetALD subcategory (62.5%), followed by ALD patients with a prevalence of 34.3% from the entire subgroup (Table 3).

Table 3 Distribution of advanced fibrosis and cirrhosis in patients with CLD.
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Table 4 Factors associated with severe fibrosis in all patients: multivariate Analyses.
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Correlation between LSM, CAP and characteristics of vulnerable patients

Based on the estimated values ​​of the correlation coefficients, we observe the existence of statistically significant links between LSM and Total proteins, platelets, albumin, AFP, FIB4, APRI, NFS, Agiles3+-score, and Agiles4-score (Fig. 3). For the other characteristics to be taken into consideration no significant correlations were found. We observe the existence of a direct and strong link between LSM and Agiles4-score (Pearson coefficient − 0.796) and Agiles3+-score (Pearson coefficient-0.682), highlighting the fact that with the increase in LSM there is also an increase in these scores. At the same time, there is a strong correlation between serological biomarkers (FIB4-index, APRI-score, and NFS-score) and the determination of liver stiffness evaluated by LSM. The most important of these scores being the FIB4-index which presents a Pearson coefficient of 0.418. Moreover, the values ​​of albumin, total proteins, AFP and platelet count correlate with LSM value. Thus, an increased value of AFP induces an increased value of LSM, and the low value of platelets and albumin correlate inversely proportionally with the value of LSM leading to its increase.

Regarding the existence of some correlations between the CAP values and the characteristics of vulnerable patients, we observed the fact that based on the estimated values ​​of the correlation coefficients, we observe the existence of statistically significant links between CAP and BMI, WC, fasting glucose levels, the value of triglycerides, and total cholesterol. Among the clinical parameters, the strongest correlations were observed between the values ​​of waist circumference (Pearson correlation coefficient of 0.347) and BMI (Pearson correlation coefficient of 0.308) with those obtained by CAP. Among the biological parameters, there are strong correlations with triglyceride values ​​(Pearson coefficient − 0.304) and with total cholesterol values ​​(Pearson coefficient − 0.159). Therefore, those parameters increased in parallel with the CAP values. However, no significant correlation between CAP, BMI, and WC levels with LSM value among vulnerable individuals was revealed.

In Table 4 we performed a multivariate analysis of factors contributing to severe fibrosis (≥ F3) for patients selected in our study. The presence of HCV-infection (aOR = 4.38, 95%CI = 2.45–7.98), HBV-infection (aOR = 3.57, 95%CI = 2.13–6.92), metabolic syndrome (aOR = 1.76, 95%CI = 0.98–2.47), alcohol use risk (aOR = 1.94, 95%CI = 1.42–2.65), INR (aOR = 23.63. 95%CI = 6.13–91.15), and AST (aOR = 1.017, 95%CI = 1.010–1.023) were directly significantly associated with the presence of severe liver fibrosis (≥ F3) in our study. Also, the levels of PLT (aOR = 0.996, 95%CI = 0.993–0.999) were indirectly substantially associated with severe fibrosis (≥ F3).

Fig. 3
figure 3

Correlation between LSM, CAP and characteristics of vulnerable patients. **Correlation is significant at the 0.01 level (2-tailed). *Correlation is significant at the 0.05 level (2-tailed). Abbreviations: LSM, liver stiffness measurements; CAP, controlled attenuation parameter, BMI, body mass index; WC, waist circumference. INR, international normalized ratio; AFP, Alpha-Fetoprotein; FIB-4, fibrosis-4 index; APRI, AST to Platelet Ratio; NFS-score, NAFLD, Non-Alcoholic Fatty Liver Disease Fibrosis score.

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Discussion

Identifying vulnerable populations requires a multidisciplinary approach that builds on each individual and physician awareness and education, access and linkage to screening and specialty services, and accountability of these populations to mitigate the burden of disease at the health system level state and world. Although assessing the entire population at high risk of chronic liver disease may be difficult, focusing on selected groups at highest risk may be a step forward, with interaction between primary care physicians and hepatologists being essential21. Expanding screening guidelines to recommend HCV and HBV-infection screening at least once in a lifetime for all adults will bring the World Health Organization (WHO) closer to its goals of eliminating viral hepatitis. A key aspect of achieving this is the pre-immigration screening of patients for viral hepatitis, which is currently carried out in few countries22.

With a mortality rate of 34.6 per 100,000 and a significant financial burden, liver cirrhosis is a major health issue worldwide, particularly in Romania23. As such, there is an urgent need to shift the pattern of chronic liver disease diagnosis from late stages (i.e., cirrhosis complications) to early stages (i.e., advanced fibrosis or compensated cirrhosis)24. According to this new perspective, noninvasive methods for assessing liver fibrosis in the general population, such as TE, should be used to identify asymptomatic patients3. Economic efficiency is a key component of the screening process, and choosing people with a high pretest probability is a key takeaway from colorectal cancer screening. According to a recent study by Serra-Burriel et al., the cost of using TE in at-risk populations, such as those with metabolic syndrome or heavy drinkers, is approximately $2000 per quality-adjusted life-year. This is less than the threshold for inclusion in the portfolio of covered services in the majority of developed regions25,26.

This prospective study conducted in North-Eastern Romania utilizing TE and CAP among vulnerable participants revealed a prevalence of advanced fibrosis and cirrhosis of 10% and 16.1%, respectively. SLD was identified in 60.2% of the entire cohort, with 35.7% displaying MASLD, 17.3% presenting ALD, and 7.2% classified as MetALD. The prevalence of HBV infection was 8.4% among individuals, while HCV infection was reported in 6.1% of cases. The prevalence of advanced fibrosis and cirrhosis varied significantly among the chronic liver disease subcategories, with the highest rates observed in MetALD participants. Furthermore, statistically significant associations have been identified between LSM and total proteins, platelets, albumin, AFP, FIB4, APRI, NFS, Agiles3+-score, and Agiles4-score.

To date, limited reports exist on the prevalence of advanced fibrosis (9.7 kPa) and cirrhosis in vulnerable populations, ranging from 7 to 26%13,14,27,28,29,30,31. However, a specific cutoff value for the dichotomization of various stages of liver fibrosis has not yet been established. Chávez-Tapia et al. conducted a study on a rural population utilizing transient elastography (TE) as a screening tool for liver fibrosis. They reported a prevalence of 8.02% (7–9 kPa) among individuals at intermediate risk of cirrhosis and 7.35% (> 9 kPa) among those at high risk of cirrhosis, and discovered that the presence of alcohol intake, T2DM, and obesity is correlated with an increased risk of cirrhosis14. These results are different from ours, since we included patients with chronic viral hepatitis, which had a prevalence of more than half of advanced fibrosis and cirrhosis.

The importance of metabolic syndrome components on the development of liver fibrosis in the vulnerable population was evaluated in the study by Kim et al. Thus, the authors included 363 vulnerable patients, initially diagnosed with hepatic steatosis. Of these, 7% presented normal weight, 68% were obese, 11% were heavy drinkers, 33% had type 2 DM, and about half had hypertension and dyslipidemia. Compared to patients without diabetes, those with diabetes had a higher prevalence of hypertension (68%), dyslipidemia (61%), and obesity (77%). Also, steatohepatitis and advanced fibrosis were more common in those with diabetes: 89% had steatohepatitis and 46% patients had advanced fibrosis, respectively27. The results of our analysis coincide with those in the literature and show us that more than a third of vulnerable subjects (37.3%) have metabolic syndrome, and approximately a quarter of the vulnerable population suffers from diabetes mellitus. A recent cross-sectional analysis which included 539 subjects with overweight, and obesity found a prevalence of advanced fibrosis and cirrhosis of 10.8% and 4.5% respectively using magnetic resonance elastography for the examination. Also, the authors showed a prevalence of SLD, MASLD, MetALD and ALD of 75%, 67.3%, 4.8% and 2.6% respectively28. These data are similarly to ours regarding the cases reported with advanced fibrosis, but presents a difference in cirrhosis prevalence, because the fact that we included a higher number of heavy drinkers (99 individuals) and patients with chronic viral hepatitis. In a different recent study, Kalligeros et al. used TE and CAP examination to diagnose steatosis and advanced fibrosis in 15,560 participants. They showed a prevalence of SLD in 37.8% cases, MASLD in 32.45%, MetALD in 2.56%, and ALD in 1.1%. They also found out that advanced fibrosis was reported 20.86% in MASLD and 8.98% in MetALD subjects29. Instead, we reported an advanced fibrosis in 6.4% patients with MASLD, and in 19.5% MetALD individuals. This difference can be explained by the fact that we included only vulnerable subjects with a high prevalence of obesity, diabetes mellitus and metabolic syndrome. The prevalence of SLD and advanced fibrosis in general population was investigated by Ciardullo et al. among USA subjects using the same cut-off values as ours for CAP and LSM of 274 dB/m and 8 kPa, for the presence of hepatic steatosis and significant fibrosis. In a cohort of 3173 participants drawn from the general community, they discovered that 42.1% of them had SLD, whereas 15.2%, 9.5%, and 19.5% of them had advanced fibrosis in MASLD, MetALD, and ALD group, respectively30.

The study of Vulnerable Adult Hepatic Disease (VALID) provided a unique medical service to assess liver fibrosis in homeless people staying in boarding houses. The purpose of this study conducted by Hashim A. et al. was to determine the prevalence of significant liver fibrosis (LSM ≥ 8 kPa). Thus, 26% of the 127 evaluated patients presented significant fibrosis, and factors associated with increased LSM values ​​were represented by excessive alcohol consumption, as well as the presence of HCV co-infection. LSM values ​​were also validated by performing the non-invasive Enhanced Liver Fibrosis score31. These data are similar with ours, the prevalence of significant fibrosis in our cohort was 34.9%, and in addition we found that the values ​​of albumin, total proteins, AFP, platelets count, FIB4, APRI, NFS, Agiles3+-score, and Agiles4-score correlate with LSM values.

A prospective, diverse cohort that underwent a thorough clinical evaluation with a detailed characterization using top-notch, cutting-edge imaging techniques and the AUDIT-C questionnaire for alcohol intake quantification is the study’s primary strength. To ensure a true cross-sectional assessment of participants in laboratory and imaging examinations, all testing was also completed on the same day. Another strength of the current research comes from the heterogeneity of the studied population concerning the etiologies of liver fibrosis, distinguishing it from other studies. Thirdly, we included a significant number of vulnerable people who did not exhibit any symptoms (571 subjects). An additional advantage of this research is that it was the first epidemiological study in Romania to give useful data on randomly unselected patients from vulnerable populations. Being a single center is the primary drawback and some of the participants were recruited from endocrinology/diabetology clinics, therefore there is a slight risk of bias. Secondly, because we enrolled healthy people, no liver biopsy was performed, therefore no histology data on people with clinically substantial liver fibrosis was examined and there was a lack of transient elastography validation for these populations. Fourthly, this is a descriptive study in which patients were analyzed at a single visit, therefore available data on therapy for patients with HBV or HCV-infection or monitoring patients with severe fibrosis (≥ F3) are not available. Furthermore, the fact that patients with clinically significant liver fibrosis did not have a second examination using alternative techniques for assessing liver fibrosis and steatosis, such as magnetic resonance elastography and 2-dimensional shear wave elastography, could be regarded as another limitation of our study. Future researchers are needed to ascertain the prevalence of advanced fibrosis in at-risk populations, and larger cohorts are necessary to evaluate potential differences in advanced fibrosis and cirrhosis among the SLD subcategories to further investigate the synergistic effects of alcohol and metabolic risk factors.

Conclusions

The prevalence of advanced fibrosis and cirrhosis was high among asymptomatic healthy individuals within vulnerable populations in North-Eastern Romania. The highest prevalence was observed in individuals with risk factors including advanced age, male gender, obesity, diabetes mellitus, chronic viral hepatitis, and excessive alcohol consumption. Furthermore, most cases involving advanced fibrosis and cirrhosis were identified as MetALD subjects, highlighting the effectiveness of the new nomenclature in capturing the etiology of liver fibrosis. In clinical practice, this should increase awareness of the higher prevalence of advanced fibrosis among individuals with significant alcohol consumption and necessitate more rigorous screening.