Fibrosis scoring systems (FIB-4 and ELF)

What are fibrosis scoring systems and when are they used?

Fibrosis scoring systems bring together a group of different test results. Doctors sometimes use them look at how much scarring there is in your liver. They might also talk about this as the stage of fibrosis.

Fibrosis scoring systems are only used for people with risk factors for liver disease. They have not been shown to be helpful for people who do not have these risk factors.

No test for liver fibrosis is perfect. Doctors will look at your liver fibrosis test alongside other test results and information about you.  They will use this to work out your individual risk of having a liver problem and what should happen next.

The amount of fibrosis in your liver can change over time. It can get better as well as worse. So you might be asked to have these tests again to see if anything has changed or to monitor your condition.

Not everyone will have these tests. You might have both of them, just one, or a different type of test such as a fibroscan. This will depend on your condition, and the policy at your hospital.

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Fib-4

Also called Fibrosis-4 index

The Fib-4 index is a calculation. It uses your age and the results of some of your blood tests to give an indication of the amount of scarring (fibrosis) in your liver.

Having a Fib-4 test

A Fib-4 index can usually be worked out from the results of a liver blood test. This is a very common test. If you have recently had it, your doctor might be able to use those results.

If not, you will have a blood test. A small amount of blood will be taken, usually from your arm.

Some medicines can affect your results. So tell your doctor about any medicines you are taking. This includes over the counter medicines, herbal and natural remedies, and supplements.

Once your doctor has your blood test results, they can use a formula to work out your Fib-4 index.

What will be tested:

The test looks at your:

• age in years. It is most reliable if you are between 35 and 65 years old
• AST level
• ALP level
• Platelet count

AST and ALP are enzymes that are made in your liver. Your platelet count is a test of how well your blood clots if you get a cut. You can find out more about all of these on the liver blood tests page.

Understanding your results and what happens next

The Fib-4 index gives you a result between 0 and 6. Based on this number you will usually be told if your fibrosis is mild, moderate or severe.

The exact cut off point for each stage can be a bit different for different people. It can also depend on where you have your tests. This information is just a guide. Speak to your medical team for a personal explanation of your score and what it means.

0-2 – Mild fibrosis

3-4 moderate cirrhosis

5-6 severe cirrhosis/ cirrhosis

If your fibrosis is mild, you probably won’t need to see a specialist. But it is a good idea to make some changes in your everyday life to help your liver to heal itself. You can find out more about eating, drinking and keeping active.

If you have moderate or severe fibrosis you are likely to be referred to a specialist or have more detailed tests.

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ELF

Also called:  enhance liver fibrosis test/score

The ELF test is a blood test. The result can tell you if you are likely to have fibrosis and how severe it might be.

Having an ELF test

The ELF test is not part of a standard liver blood test. You might need to have a blood sample taken for the ELF test or as part of a full liver screen.

A small blood sample will be taken, usually from your arm. The ELF test looks at several things, but these tests can all be done from one tube of blood.

What will be tested?

• Hyaluronic acid (HA)
• A protein called procollagen III amino terminal peptide (PIINP)

These are both involved in forming scars (fibrosis)

• An enzyme called matrix metalloproteinase 1 (TIMP-1).

High levels of TIMP-1 can make it hard for your liver to clear away scar tissue.

Understanding your results and what happens next.

The ELF scoring system will give you a number. The higher the number, the more fibrosis your liver is likely to have. ²

Based on your number, you might be told that your fibrosis is mild, moderate, severe or cirrhosis.

In general, if your ELF score is below 9.8 your fibrosis is mild or moderate. In this case your GP will look after your care. You may be told to make some changes in your life to help your liver repair that damage. You can find out more about eating, drinking and keeping active here.

If your score is 9.8 or higher then you could have more severe fibrosis. You should be referred to a specialist for more tests.

The numbers on this page are a rough guide. The exact numbers used for each of these stages can be a bit different depending on where you have the test. So it is very important to talk to your medical team for personal information about what your results mean.

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Questions to ask your medical team

Fibrosis scoring systems and complicated and exactly what they mean is different for everyone. If you have a follow up appointment, it can  help to write down some questions in advance to help you get the most out of it.

Here are some suggestions for questions to ask your doctor or nurse:

• What stage is my fibrosis? How sure are you about that?
• Should I have any other tests?
• Should I have this test again to see if anything changes?
• What should happen next – what are my options?
• If I need to make some changes in my life, is there any help or support available?

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Support for you

The British Liver Trust offers a range of support for people with a liver condition and those closest to them. This includes support groups and an online forum. Support for you.

You can also call or email our helpline. Our friendly team of specialist liver nurses cannot give you a diagnosis or interpret test results. But they can answer questions, offer support, or just listen.

Call the helpline on 0800 652 7330 or find out more here.

We also have lots of information about liver disease and living with a liver condition:

• Liver blood tests (LFT)
• Tests for liver conditions
• Take our free online screener
• Liver conditions A to Z
• Useful words glossary
• Living with a liver condition
• Eating, drinking and keeping active
• Mental health

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Special thanks

We would like to thank everyone with lived experience of liver disease tests who helped with these pages. Also, Professor Stephen Ryder, consultant hepatologist at Nottingham University Hospitals NHS trust for reviewing this page.

Published: July 2025

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